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A physician advisor can be invaluable if the hospital chooses the right person for the role, says Yvonne Focke, RN, BSN, MBA, a Cincinnati-based independent case management consultant.
It’s important to choose a physician advisor who has the personality and the finesse to have difficult conversations with other physicians without putting them on the defensive, Focke says. At the same time, they have to be approachable and open to input from case managers, she says.
Physician advisors should be well-respected by their colleagues, knowledgeable about admission criteria and reimbursement, accessible, approachable, articulate, and collaborative, she adds.
“We recommend that hospitals identify someone on the medical staff or in the community who already knows the hospital medical staff and has credibility with other physicians,” says Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
A small hospital could combine the roles of chief medical officer and physician advisor, she adds.
Start your search with the hospital’s medical staff and look for an experienced practitioner who is not ready to retire but is ready for a shift from managing an office and might be interested in a leadership role, Lamkin suggests. Perhaps start with physicians who have already been in medical staff leadership positions.
She recommends avoiding physicians whose practices depend on the referrals of other physicians. It could shape their judgment when dealing with the medical staff.
Physician advisors need to be familiar with Medicare and Medicaid regulations, understand the contractual agreements with private payers, and be knowledgeable about inpatient criteria sets, Focke says.
“They need to understand what the case manager’s job is and why they got called on that particular case,” she says.
Focke recommends having physician advisors who are experienced in internal medicine or family practice. “Specialists may not be ideal because the role requires someone with broader knowledge,” she says. In many hospitals, hospitalists are the physician advisors, she says.
Hospitals should develop a job description for the physician advisor and include where they fit in on the organizational chart.
Before asking the hospital administration for a physician advisor, do your homework, Focke advises.
Look at your denial rate and determine why cases are being denied. Tally the cases that could have been avoided if you had a physician advisor and determine the cost-benefit ratio. “Look at the volume and where the need is and decide if it would be best to outsource the job or to hire from within,” Focke says.
Physician advisors have the expertise and the clout to help case managers ensure that patient status is correct on the front end but they can do so much more, Lamkin says.
Physician advisors typically serve on hospitals’ utilization management committee, and oftentimes chair the committee, Lamkin says.
“The utilization management is one of the most important committees in the hospital as they begin to look at how billing is affected by the medical staff or clinical practice. The physician advisor should sit on the committee and look at trends in denials and discuss the situations with the committee and then provide education for the physicians,” she says.
The case management department should provide the infrastructure and resources required by the Medicare Conditions of Participation to support the utilization management committee, Lamkin says.
For instance, the department should provide someone to send out notices of meetings, create an agenda, pull together any data needed, and coordinate identification of cases to be reviewed, Lamkin says.
In addition, the case management department should be tracking quality information, denials, avoidable days, and other data and reporting any patterns to the utilization management committee.
“Every case management department should have an analyst who developed trending score cards and dashboards so the physician advisor has all the information needed to have an effective meeting, and data that enables the committee to identify areas for improvement,” she says.
The physician advisor should be involved with managed care contracting and work with the contracting department to ensure the terms of contracts are friendly to the hospital and can be executed, Lamkin says.
They are the best people to negotiate with private payers when there is a disagreement on bed status or continuing an inpatient stay, she says.
They can assist the clinical documentation improvement staff in obtaining documentation that supports the level of care needed and the need for services the patients received and educate other physicians on the need for documentation.
Physician advisors can be the case management department’s ally in convincing the hospital management to add staff positions, Focke says.
“Physician advisors can be the interface between hospital leadership and the case management department and can help the hospital administrators understand the value of case management and why case managers are critical to the hospital’s bottom line,” Focke says.
Financial Disclosure: Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Editor Mary Booth Thomas, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Nurse Planner Toni Cesta, PhD, RN, FAAN, Consulting Editor of Hospital Case Management, is a consultant with Case Management Concepts LLC.